ATI SKILLS- VITAL SIGNS Flashcards
INSPIRATION
an active process that involves the diaphragm moving down, external intercostal muscles contracting, and the chest cavity expanding to allow air to move into the lungs
expiration
a passive process that involves the diaphram moving up, external intercostal muscles relaxing, and the chest cavity returning to its normal resting state
what regulates breathing
respiratory center in the medulla of the brain and the level of co2 in the blood
what components are involved in the accurate assessment of respiration
rate, depth, and rhythm
what factors can alter a client’s respiratory rate
exercise, anxiety, fever, low hemoglobin can all increase
neurological injuries and meds can slow the respiratory rate
tachypnea
rr faster than 20/min
bradypnea
rr slower than 12/min
cheyne stokes
breathing cycles that increase in rate and depth and then decrease and are followed by a period of apnea
causes of cheyne stokes
heart failure
increased intracranial pressure
eol
biot’s respirations
period of slow and deep or rapid and shallow breathing followed by apnea
causes of biot’s respirations
cns abnormalities
kussmaul’s respirations
deep and gasping respirations
what causes kussmaul’s respirations
renal failure
septic shock
diabetic ketoacidosis
depth of breathing
aka tidal volume
amount of air that moves in and out of the lungs with each breath
what instrument determines precise tidal volume
spirometer
how can you estimate tidal volume
by observing the expansion and symmetry of chest wall movement during inspiration and expiration
the binaural assembly of a stethoscope includes what parts
ear tips (earpieces)
ear tubes (binaurals)
tubing
bell of the stethoscope
cup shaped
for low pitched sounds
diaphragm
flat/drum-like part
high pitched sounds
what does the strength of the pulse correlate with
the volume of blood being ejected against the arterial walls with each contraction of the heart
blood volume affect on pulse
decrease- weak and difficult to palpate
increase- bounding and easy to palpate
radial pulse
easiest to access
most frequently checked peripheral pulse
normal adult pulse rate ranges
60-100/min
factors affecting pulse
sex (higher in women)
age (higher in infants/children)
exercise
meds
decreased SaO2
blood loss
temp
bradycardia
pulse less than 60/min
thyroid activity, kyperkalemia, irregular cardiac rhythm
increased intracranial pressure
tachycardia
hr faster than 100/min
chf
hemorrhage
shock
dehydration
anemia
dyspnea
sensation of difficult or labored breathing
why palpate a client’s pulse
determine circulation distal to the pulse site and for rhythm, guality, and strength
apical pulse
most reliable noninvasive way to assess cardiac function
s1
tricuspid and mitral valves close at the end of ventricular filling and just before systolic contraction
s2
when the pulmonic aortic valves close at the end of systolic contraction
determining an apical pulse
use anatomical landmarks for correct placement of the stethoscope over the apex of the heart so you can hear the heart sounds clearly
how long to count pulse
30 seconds
1 minute if irregular
when to use the apical pulse
when the client has a history of heart related problems or is taking cardiovascular meds
count while pt is at rest
if pt has been active, wait 5-10 minutes
how to calculate pulse deficit
subtract radial pulse rate from the apical pulse rate
takes 2 people counting at the same time for 1 minutes
pulse deficit
occurs when the heart contracts inefficiently and does not transmit a pulse wave to peripheral sites
sign of alterations in cardiac output
sphygmomanometer
basic nonelectric blood pressure cuff
correct bp cuff size
20% greater than the diameter of the limb at its midpoint or 40% of circumference
what is bp
force that blood exerts against the vessel wall
systole
when the ventricles of the heart contract forcing blood into the aorta
diastole
low point
when the ventricles relax and minimal pressure is exerted against the vessel wall
normal bp ranges for adults
90-119mmHg/ 60-79 mmhg
normal blood volume
remains constant at 5000 mL
factors affecting bp
blood volume
age
ethnicity
sex
position changes
exercise
weight
anxiety
meds
time of day
nicotine use
how is bp measured in hemodynamically unstable pts
invasively by inserting a small catheter into the brachial, radial, or femoral artery
when should an aneroid manometer be calibrated
every 6 months
the bladder of the bp cuff should encircle what
at least 80% of the arm
*make sure to note the size of the cuff it is not a standard adult cuff
5 korotkoff sounds
- clear rhythmic tapping that coincides with the systolic bp
- whooshing sound
- knocking sound
- softer blowing sound that fades
- disappearance of sounds (diastolic bp)
*if you hear sounds all the way to 0 mmHg, record the 4th sound as the diastolic bp
pullse pressure
difference between the systolic and diastolic values
number is usually between 30 and 50 mmHg
hypertension
2+ high bp readings at 2+ visits after the baseline is obtained
how can you control htn
diet
exercise
antihypertensive meds
hypotension
low bp
reports of feeling dizzy or lightheaded
orthostatic hypotension
systolic drops/increases more than 20 mmHg when client moves from recumbent to sitting position and then standing position
related to decrease blood volume, prolonged bed rest, older age, and meds
if the client has coarctation of the aorta (a congenital heart defect), how will bp be affected
arm bp will be higher than leg bp
when to assess bp in lower extremities
can’t measure bp on upper extremities
brm bp in adolescent/young adult seems unusually high
two areas of the leg where you can measure bp
- thigh just above the knee using the popliteal pulse. 1 inch above the popliteal arter with the bladder over the posterior aspect of the mid thigh
- calf just above the ankle using the posterior tibial pulse
bp differences when using lower extremities
- systolic reading in the thigh is usually 10-40 mmHg higher than in the arm while diastolic usually remains the same
common types of thermometers
electronic
tympsnic
temporal
chemical dot/ strip
why dont many hcf no longer use mercury thermometers
environmental hazards that these devices pose
parts of electronic thermometer
rechargeable/battery powered display
thin wire cord
2 temp probes
blue tipped probe
oral temp
red tipped probe
rectal temp
what does a tympanic thermometer consist of
otoscope-like tip with an infrared sensor on the end thay detects head radiated from the tympanic membrane
tympanic membrane
thin, semi transparent membrane that separates the auditory canal from the middle ear or tympanic cavity
to obtrain an accurate reading from a tympanic thermometer it is important to
place the probe at the proper angle for sealing the ear canal
when not to use the tympanic site for temp
reports of ear pain
excessive earwax
drainage from ear
sores/injuries in/around the ear
temporal thermometer
has round/rubber like probe that measures skin temp over temporal artery
how to use temporal thermometer
while pressing scan, hold probe flat against of forehead while moving it gently across the forhead over the temporal artery and then touch to the skin behind the earlobe. then release scan button
chemical dot single use temp
disposable strips of plastic with a temp sensor at one end
applied to areas of skin such as forehead/abdomen
consists of chemically treated dots that change color at different temps
celsius strips- 50 dots, increments of 0.1 degrees. covers range of 35.5-40.4 degrees celcius
farenheight strip-45 dots, increments of 0.2 degrees, range of 96.0-104.8
inexpensive, unbreakable, used in isolation rooms
goal of obtaining body temp
obtain a representative average temp of core body tissues
temp varies depending on
blood flow to the skin
heat lost to external environment
sites reflecting core temp are more reliable
best sites for temp
depend on age, situation, agency policy
proper use of tthermometer
correct documentation
*for comparison, use same site each time
factors affecting temp
age
exercise
hormones
stress environmental temp
time of day
body site
meds
normal temp
oral range of 36.0-38.0 degrees celsius or 96.8-100.4 degrees F
rectal temp is a core temp that what
is usually 0.5 C to 0.9 F higher than oral temp
axillary temps are usually what
0.5 C or 0.9 F lower than an oral temp
F to C
F-32+5/9
C to F
9/5C+32
when to use oral temp
most adults
children usually by 5 yrs
oral temp contraindications
client has been eating, drinking, smoking, exercising
wait 10-30 minutes
how to assess oral temp
use protective cover
place probe in sublingual pcket
close mouth
breathe through nose
hold probe in place without lips
do not bite down
when to use rectal temp
least preferred
comatose
facial injuries
deformities
critically ill/injures
infants/young children- unless certain diagnoses and less than 1 month old
to measure a rectal temp:
wear gloves
disposable sheath
lubricate 1 inch with water soluble lubricant
for adult, separate buttocks and inser and hold probe approx 1 inch into rectum in direction of umbilicus
if taking rectal temp and you feel resistance
remove immediately
do not force as it could injure rectal mucosa
when to use axillary temp
axilla is appropriate for most adults and children including infants
not as accurate
does not reflect core body temp of adult
do not use if open sores or rashes
an axillary temp is generally
0.9F or 0.5C lower than mouth or ear
factors affecting axillary temp
time of day
level of activity prior
why use temporal artery temp
- suitable for all ages
- no risk of injury
- *do not use if area has been covered with a hat
temporal arterty temp discrepancies
close to rectal temp but nearly 1F (0.5C) higher than oral temp and 2F (1C) higher than axillary
pulse oximektry
quick and noninvasive way to measure oxygen saturation
how a pulse ox works
reading the light reflected from hemoglobin molecules that are saturated with oxygen
consists of a sensor with a led that is connected to the oximeter by a cable
expected frange for oxygen saturation
95-100%
how to obtain the best SaO2 reading
place sensor on vascular area of body like fingers, toes, earlobes, bridge of nose
factors affecting SaO2 readings
nail polish
artificial nails
movement
hypothermia
meds that cause vasoconstriction
peripheral edema
hypotension
abnormal hemoglobin level
pain
5th vs
affects physical, emotional, and mental well being
must be managed immediately and effectively so client can perform ADLs
acute pain
severe
rapid onset
short duration
resolves with healing
chronic pain
continues beyond point of healing
often more than 6 months
cancer pain
category of its own
can be acute, chronic, or intermittent
caused by tumor growth and tissue necrosis
cries pain scale
assessing postoperative pain in perterm and term neonates
behavioral and physiologic indicators are measured on a three point scale
faces and oucher pain scale
used with peds
client points to face that best matches how they feel about pain
numeric pain scale
used for teens/adults
rate on 0-10
descriptor pain scale
for older adults
lists words that describe different levels of intensity
impaired cognitive abilities or cannot respond verbally- assess nonverbal cues like facial expressions, behavior, moaning, vocal sounds, unusual movements
managing pain
implement pharmacological and nonpharmacological interventions
meds hsould be prescribed/administered on a regular schedule
some meds on a prn basis
managed on an individual basis
do baseline vs predict clinical deterioration
vs predict rapid response team activation within 12 hours of ed admission
why is pain the 5th vs
quality of care is improved when pain is evaluated and managed
why is it so important to establish vs baselines
to help evaluate circulatory, pulmonary, endocrine, and nerological functioning
become basis for comparison later
may need second person to verify
what measures must i take when assessing vs of a client requiring more than standard precautions
do not share
disposable/single use thermometers are idea
clean stetho and bp equipment
what do core body temp and surface body temp mean
difference between heat production and loss
core temp is higher than surface temp and measured at tympanic and rectal sites, esophagus, pulmonary arter, bladder invasive devices
suface temp measures skin temp and measured at oral and axillary sites
is it acceptable to use a glass thermometer
if filled with alcohol or petroleum based liquid
used in critical care units
used if client is on isolation precautions
what physical effects do clients experience with fever (aka pyrexia)
hot/dry skin
loss of appetite
headache
general malaise
thirst
periods of delirium or seizures
infant and older adult temp discrepancies
infants younger than 3 months may display mild elevation despite serious infection
older adults have lower baseline so fever may be later sign of illness despite extensive patho processes
what can i do to reduce fever
control environmental temp (cooler room, remove clothing/blankets, bed linens dry, limit activity, admin antipyretic agents
which clinical conditions require frequent temp checks
infection
open wounds/burns
blood count less than 5000/mm3
blood count more than 12000/mm3
postop
receiving blood products
use of suppressive medication therapy
injury to hypothalamus
exposure to temp extremes
use of hypothermia/hyperthermia therapy
hyperthermia
elevation of core temp that results in overload of thermoregulatory mechanisms
causes tachycardia, decreased turgor, hypotension, concentrated urine, decreased venous filling
heatstroke
results from prolonged heat exposure
dry/hot skin
tachycardia
hypotension
excessive thirst
muscle cramps
confusion/hallucinations
visual disturbances
hypothermia
drop in temp to less than 96.8F (36C)
pale skin
cool/cold skin
uncontrolled shivering
reduced loc
shallow respirations
bradycardia
dysrhythmias
pulse deficit
difference btw apical and radial pulse counted at the same time by 2 providers
difference of more than 2/min indicates possible alterations in cardiac output
heart pulsations generally are not reaching peripheral arteries
when should i expect alterations in apical pulse
heart disease
cardiac dysrhythmias
sudden onset of chest pain
sudden pain onset
internal bleeding
external bleading
surgery
invasive cardio diagnostic tests
sudden and large volume of iv fluid
certain meds
ventilation
mechanical process involving movement of gases in and out of lungs
diffusion
movement of o2 and co2 between alveoli and rbc
perfusion
process of blood distribution (pulmonary circulation) to and from the abg barrier in pulmonary capillaries where gas exchange occurs
why assess rr after counting hr
allows you to evaluate rr inconspicuously so that client doesn’t alter depth and rate of respirations
what are my responsibilities related to vs assessment
requires knowledge of expected vs variations
ability to incorporate factors affecting vs to individual care plans
double check findings and reassess continually if problematic or unexpected manifestations
ensure accuracy in measurements and reporting
can a client with low hemoglobin appear to have normal SpO2
yes because most hgb is saturated, yet may not have enough o2 to meet body needs
which is the primary reason for assessing vs
1. establish baseline when client reports no specific health related problem
2. determine presence of any acute or chronic illness/disease
3. initiate nursing process
1
which accurately describe body temp
1. difference between het produced by and lost from the body
2. total heat produced by the body
3. amount of heat produced by body plus heat lost to the external environment
1
which tympanic temp is documented correctly and within expected reference range for adults
1. T= 98.6F
2. T=99.6F (T)
3. T=101.0F (T)
2
which is true regarding assessing pulse
1. pulse is the palpable bounding of blow flow in a peripheral arter
2. expected range for adult at rest is 50-110/min
3. 3 components when documenting are rate, rhythm, and depth
4. if rhythm is irregular, count hr for 30 seconds and multiply by 2
1
which is true when assessing respiration
1. inform client you are assessing respiration
2. document as “rr 14/min, regular rhythm and depth
3. ;expected finding of older adult is irregular patterns
4. anxiety and acute pain should not affect rr
2
which describes systolic pressure
1. roce blood exerts on vessel wall during contraction and relaxation phases
2. pressure extered during contraction
3. pressure exerted during relaxation
2
clients bp is 166/88 mmHg. which category is the bp in
1. expected range
2. slightly elevated
3. hypertensive crisis
4. htn stage 2
4
bp was high and you reassess, which are appropriate to ask before reassessing
1. what is usual bp
2. have you eatien within the last hour
3. did you drink tea, coffee, or soda within the last half hour
4. are you experiencing stress, fear, anxiety
5. have you smoked within the last 15-30 min
select all that apply
1, 3, 4, 5
how long to wait before reassessing bp on the same arm
1. 1-3 minutes
2. 10-15 minutes
1
what is the most appropriate way to document bp
1. bp is 160/90
2. bp 160/90 right arm, sitting
3. bp= htn at 160/90
2
you are taking temp using tympanic thermometer. denies ear pain or drainage. inspect ear canal for what?
1. symmetry
2. sensitivity
3. cerumen
3
you support arm and palpate wrist to locate radial pulse along groove located at which position
1. dorsal aspect
2. down the center
3. on the thumb side
3
you compress the radial artery with which of the following
1. pad of fingers
2. tips of finger
3. pad of thumb
a
how long should you count pulse
1. 15 seconds multiplied by 4
2. 20 seconds multiplied by 3
3. 30 seconds multiplied by 2
3
why observe breathing pattern immediately without changin hand position?
1. keep client from alterting rate, rhythm, or depth
2. use time conserving methods
3. offer reassurance with touch
1
selecting bp cuff that is too small for arm will result in which
1. falsely high reading
2. falsely low reading
1
which is an explanation for removing outer sweater
1. ensure proper application
2. prevent falseyly high readings
3. make client more comfortable
4. allow for cuff bladder to inflate properly
5. elminicate muffling of korotkoff sounds
a, b, d, e
you place lower edge of cuff at lease 1 inch above the antecubital space to do what
1. allow for proper placement of stetho
2. facilitate proper flexing of elbow
3. ensure appropriate application of pressure to brachial artery
a
why is supporting arm at heart level important
1. unsupported arm can cause falsely high reading
2. arm position below heart can cause falsely high reading
3. arm positioned below heart can cause falsely low reading
4. ensure good blood flow conducive to accurage reading
select all that apply
1, 3
to ensure accurate reading with aneroid sphygomomanometer, position yourself in which of the following
1. within 3 feet
2. at eye level with gauge
3. standing at side
4. where you feel most comfortable
select all that apply
1, 2
if no bp baseline, which is appropriate
1. measure on one arm, wait 2 minutes, measure on other arm, average the values
2. measure, reinflate promptly, measure, average
3. inflate to 30 mmHg above the point of palpated systolic pressure
4. ask what bp usually is and inflate to 30 mmHg above that point
select all that apply
1, 3
what is the proper technique for bp cuff inflation and deflation
1. rapid inflation and deflation
2. slow inflation, slow deflation
3. rapid inflation, slow deflation
4. slow inflation, rapid deflation
3
when listening to korotkoff sounds, use which part of stetho
1. bell
2. disphragm
select all that apply
1, 2
in which location should the stetho be positioned to auscultate apical pulse at the point of maximal impulse (pmi)
1. over right midclavicular line
2. over angle of louis
3. over 5th intercostal space at left midclavicular line
4. over suprasternal notch
3
which action should be taken when assessing respiration
1. have them lie flat with head on pillow
2. elevate bed to 45-60 degrees
3. encoure slow breathing
4. ask them to take several deep breaths prior
2
which definds the difference between systolic and diastolic bp
1. ausculatory gap
2. pulse pressure
3. orthostatic hypotension
4. pulse deficit
2
which factor does the reading at the 4th korotkoff sound correlate to on the manometer
1. systolic pressure
2. second diastolic pressure
3. loudest korotkoff sounds
4. might no follow with 5th sound
4
which action should you take to determine depth of respirations
1. observe degree of chest wall mvmt during inspiration/expiration
2. count breathing cycles observed per minute
3. notice whether or not expiration takes longer than inspiration
4. measure precise amt of air client takes in and breathes out
1
which finding is priority to report to the provider
1. 100F oral temp
2. rr 30/min
3. bp 148/88 mmHg
4. radial pulse of 45/30 seconds
2
client has new onset of 102F temp. which other vs should be expected
1. elevated hr
2. decreased bp
3. elevated bp
4. decreased hr
1
which action should be taken when measureing oral temp
1. place probe in posterior lingual pocket lateral to midline
2. rest probe on lower lingual frenulum
3. place probe centrally on top of tongue
4. rest probe under tongue just beyond teeth
1
s2 heart sounds are heard when?
1. atria contracts vigorously
2. ventricular walls contract
3. semilunar valves close
4. mitral valves snap open
3
which should be taken to ensure accurate tympanic temp reading
1. attach disposable cover
2. assess external ear for redness
3. pull pinna back and upward
4. replace thermo in charger
3
which factors affect vs readings
1. bmi of 35
2. nausea for 2 days
3. stuffy nose
4. fasting for blood tests
5. digoxin for irregular hr
6. mastectomy 2 years ago
select all that apply
1, 3, 5, 6
which action should nurse take to determine rectal temp
1. reotate probe with resistance
2. inser probe aimed pelvic area
3. dip probe about 2 inches into lubrican
4. place probe 1 inch into anus
4
which action should be taken to measure bp accurately
1. obtain in early morning
2. use appropriate size cuff
3. assist to the bathroom to void
4. apply cuff loosely
2
which action should be taken to establish baseline for respirations
1. instruct to inhale/exhale normally
2. count rr for 15 seconds and multiply by 4
3. determine Hx of chronic respiratory problems
4. observe chest movements while appear to assess pulse
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